Atrial Fibrillation in the Young: A Neurologist’s Nightmare

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia seen in clinical practice with prevalence in excess of 33 million worldwide. Although often asymptomatic and until recently considered a “benign” arrhythmia, it is now appreciated that thromboembolism resulting from AF results in significant morbidity and mortality predominantly due to stroke. Although an arrhythmia more commonly affecting the elderly, AF can also occur in the young. This review focuses on the impact of AF in the younger population and discusses the dilemmas of managing younger patients with AF

Tuberculous Constrictive Pericarditis

Introduction: Constrictive pericarditis is characterized by constriction of the heart secondary to pericardial inflammation. Cardiovascular magnetic resonance (CMR) imaging is useful imaging modality for addressing the challenges of confirming this diagnosis. It can be used to exclude other causes of right heart failure, such as pulmonary hypertension or myocardial infarction, determine whether the pericardium is causing constriction and differentiate it from restrictive cardiomyopathy, which also causes impaired cardiac filling. Case Presentation: A 77-year-old man from a country with high incidence of tuberculosis presented with severe dyspnea. Echocardiography revealed a small left ventricle with normal systolic and mildly impaired diastolic function. Left heart catheterization revealed non-obstructive coronary disease, not felt contributory to the dyspnea. Anatomy imaging with cardiovascular magnetic resonance imaging (CMR) showed global, severely thickened pericardium. Short tau inversion recovery (STIR) sequences for detection of oedema/ inflammation showed increased signal intensity and free breathing sequences confirmed septal flattening on inspiration. Late gadolinium imaging confirmed enhancement in the pericardium, with all findings suggestive of pericardial inflammation and constriction. Conclusions: CMR with STIR sequences, free breathing sequences and late gadolinium imaging can prove extremely useful for diagnosing constrictive pericarditis

Cardiovascular magnetic resonance:Diagnostic utility and specific considerations in the pediatric population

Cardiovascular magnetic resonance is a non-invasive imaging modality which is emerging as important tool for the investigation and management of pediatric cardiovascular disease. In this review we describe the key technical and practical differences between scanning children and adults, and highlight some important considerations that must be taken into account for this patient population. Using case examples commonly seen in clinical practice, we discuss the important clinical applications of cardiovascular magnetic resonance, and briefly highlight key future developments in this field

Incremental benefit in correlation with histology of native T1 mapping, partition coefficient and extracellular volume fraction in patients with aortic stenosis

Background: We investigated the histological correlation of native T1 maps, partition coefficient and extracellular volume fraction (ECV) using an 11 heart beat (11 HB) MOLLI for identification of overall burden of fibrosis. Methods: Ten patients (8 male, age 73 ± 7 years; all in sinus rhythm, 2 with ventricular ectopy) with severe aortic stenosis (3 with coexisting coronary artery disease) scheduled for surgical aortic valve replacement underwent CMR on a 1.5T scanner (MAGNETOM Avanto, Siemens Healthcare, Erlangen). The 11HB MOLLI sequence (Siemens investigational prototype WIP 448B) was acquired before and 15 minutes post 0.1 mmol/kg gadolinium administration. Incorporating hematocrit results from the same day. This allowed native T1 maps, partition coefficient and ECV calculation. Images were obtained twice at end diastole at basal, and twice at mid left ventricular level. The average of all measurements was used to calculate ECV using the standard formula Partition Coefficient= [(1/T1myocardium post contrast-1/T1 myocardium native)]/[(1/T1 blood post contrast-1/T1 blood native)] with x(1-HCt) for ECV. Similar regions of interest were drawn in the septum at both levels for T1 values. Intraoperatively, trucut biopsies were taken from the left ventricular apical anterior/ lateral wall through the epicardium to allow histological characterization of the full myocardial wall, and fixed in warm buffered formalin. Histological analysis of formalin-fixed paraffin-embedded, transmural myocardial biopsies of the left ventricle was performed on hematoxylin/eosin and Picrosirius red-stained 3-micron-thick sections by a blinded experienced cardiac pathologist. Images were analysed using a purpose-built software (Nikon NIS elements BR) on a NIKON Eclipse light projection microscope to determine the extent of overall and reactive interstitial fibrosis, which was expressed as collagen volume fraction (%) per square millimetre. Results: Native T1 mapping, partition coefficient and ECV all correlated with histologically measured fibrosis. However, native T1 mapping showed the least accuracy (panel A, R2 = 0.42) and ECV showed the highest accuracy (panel B, R2 = 0.83). Partition coefficient was more accurate than native T1 mapping but only very marginally less so than ECV (panel C, R2 = 0.80). Conclusions: These results suggest that native T1 mapping is less accurate than partition coefficient and ECV for overall fibrosis. Therefore, post gadolinium images to enable calculation of partition coefficient and ECV should be routinely obtained to increase accuracy

A novel cardiovascular magnetic resonance risk score for predicting mortality following surgical aortic valve replacement

The increasing prevalence of patients with aortic stenosis worldwide highlights a clinical need for improved and accurate prediction of clinical outcomes following surgery. We investigated patient demographic and cardiovascular magnetic resonance (CMR) characteristics to formulate a dedicated risk score estimating long-term survival following surgery. We recruited consecutive patients undergoing CMR with gadolinium administration prior to surgical aortic valve replacement from 2003 to 2016 in two UK centres. The outcome was overall mortality. A total of 250 patients were included (68 ± 12 years, male 185 (60%), with pre-operative mean aortic valve area 0.93 ± 0.32cm2, LVEF 62 ± 17%) and followed for 6.0 ± 3.3 years. Sixty-one deaths occurred, with 10-year mortality of 23.6%. Multivariable analysis showed that increasing age (HR 1.04, P = 0.005), use of antiplatelet therapy (HR 0.54, P = 0.027), presence of infarction or midwall late gadolinium enhancement (HR 1.52 and HR 2.14 respectively, combined P = 0.12), higher indexed left ventricular stroke volume (HR 0.98, P = 0.043) and higher left atrial ejection fraction (HR 0.98, P = 0.083) associated with mortality and developed a risk score with good discrimination. This is the first dedicated risk prediction score for patients with aortic stenosis undergoing surgical aortic valve replacement providing an individualised estimate for overall mortality. This model can help clinicians individualising medical and surgical care

Osteoprotegerin and Myocardial Fibrosis in Patients with Aortic Stenosis

Left ventricular myocardial fibrosis in patients with aortic stenosis (AS) confers worse prognosis. Plasma osteoprotegerin (OPG), a cytokine from the TNF receptor family, correlates with the degree of valve calcification in AS, reflecting the activity of the tissue RANKL/RANK/OPG (receptor activator of nuclear factor κΒ ligand/RANK/osteoprotegerin) axis, and is associated with poorer outcomes in AS. Its association with myocardial fibrosis is unknown. We hypothesised that OPG levels would reflect the extent of myocardial fibrosis in AS. We included 110 consecutive patients with AS who had undergone late-gadolinium contrast enhanced cardiovascular magnetic resonance (LGE-CMR). Patients were characterised according to pattern of fibrosis (no fibrosis, midwall fibrosis, or chronic myocardial infarction fibrosis). Serum OPG was measured with ELISA and compared between groups defined by valve stenosis severity. Some 36 patients had no fibrosis, 38 had midwall fibrosis, and 36 had chronic infarction. Patients with midwall fibrosis did not have higher levels of OPG compared to those without fibrosis (6.78 vs. 5.25 pmol/L, p = 0.12). There was no difference between those with midwall or chronic myocardial infarction fibrosis (6.78 vs. 6.97 pmol/L, p = 0.27). However, OPG levels in patients with chronic myocardial infarction fibrosis were significantly higher than those without fibrosis (p = 0.005)